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Tuesday, September 30, 2014

Heart Screenings for Athletes - Are they worth it?

In recent years I've been getting more and more reports of athletic heart screenings. The schools and sports clubs locally are offering for athletes to get a heart work up for a relatively small fee.

Why are they offering this? Because sudden cardiac death in athletes has been in the news a lot over the years, and we all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk. Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator. (Side note: if you've not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow "A B C" so it is very different. CPR is recommended for all teens and adults.)

Is the cost of a heart screen worth it?

A new report, Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology, is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation and is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD). Complex issues from the Statement linked above:
  1. the low prevalence of cardiovascular diseases responsible for SD in the young population
  2. the low risk of SD among those with these diseases
  3. the large sizes of the populations proposed for screening
  4. the imperfection of the 12-lead ECG as a diagnostic test in this venue 
It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: To do an ECG screening on all athletes is not inheritantly unwarranted nor discouraged, but it isn't recommended either.

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is available below.

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive.
If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time, so one normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so. The evidence does not support mass required screenings.

If however, your child has identified risks based on the questionnaire, a more thorough testing should be done.

These 14 points are listed in Table 1 of the above linked statement:

The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history* 
  Personal history
    1. Chest pain/discomfort/tightness/pressure related to exertion
    2. Unexplained syncope/near-syncope†
    3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
    4. Prior recognition of a heart murmur
    5. Elevated systemic blood pressure
    6. Prior restriction from participation in sports
    7. Prior testing for the heart, ordered by a physician

 Family history
    8. Premature death (sudden and unexpected, or otherwise) before 50 y

of age attributable to heart disease in 1 relative
    9. Disability from heart disease in close relative <50 y of age

    10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination
    11. Heart murmur‡
    12. Femoral pulses to exclude aortic coarctation 

    13. Physical stigmata of Marfan syndrome
    14. Brachial artery blood pressure (sitting position)§

AHA indicates American Heart Association.
*Parental verification is recommended for high school and middle school athletes.
†Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
§Preferably taken in both arms.
Modified with permission from Maron et al.3 Copyright © 2007, American Heart Association, Inc.